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Chem. Res. Toxicol. 2010, 23, 1356–1364
The Inhaled Glucocorticoid Fluticasone Propionate Efficiently Inactivates Cytochrome P450 3A5, a Predominant Lung P450 Enzyme Takahiro Murai,† Christopher A. Reilly,† Robert M. Ward,‡ and Garold S. Yost*,† Department of Pharmacology and Toxicology, UniVersity of Utah, 30 S 2000 E, Room 201, Salt Lake City, Utah 84112, and Department of Pediatrics, UniVersity of Utah, Williams Building, P.O. Box 581289, Salt Lake City, Utah 84158 ReceiVed April 2, 2010
Inhaled glucocorticoid (GC) therapy is a vital part of the management of chronic asthma. GCs are metabolized by members of the cytochrome P450 3A family in both liver and lung, but the enzymes are differentially expressed. Selective inhibition of one or more P450 3A enzymes could substantially modify target and systemic concentrations of GCs. In this study, we have evaluated the mechanism-based inactivation of P450 3A4, 3A5, and 3A7 enzymes by GCs. Among the five major inhaled GCs approved for clinical use in the United States, fluticasone propionate (FLT) was the most potent mechanism-based inactivator of P450 3A5, the predominant P450 enzyme in the lung. FLT inactivated P450 3A5 in a time- and concentration-dependent manner with KI, kinact, and partition ratio of 16 µM, 0.027 min-1, and 3, respectively. In contrast, FLT minimally inactivated P450 3A4 and did not inactivate 3A7, even with a concentration of 100 µM. The inactivation of P450 3A5 by FLT was irreversible because dialysis did not restore enzyme activity. In addition, the exogenous nucleophilic scavenger GSH did not attenuate inactivation. The prosthetic heme of P450 3A5 was not modified by FLT. The loss of P450 3A5 activity in lung cells could substantially decrease the metabolism of FLT, which would increase the effective FLT concentration at its target site, the respiratory epithelium. Also, inactivation of lung P450 3A5 could increase the absorption of inhaled FLT, which could lead to high systemic concentrations and adverse effects, such as life-threatening adrenal crises or cataracts that have been documented in children receiving high doses of inhaled GCs. Introduction Asthma is a chronic disease of the airways characterized by bronchoconstriction hyper-reactivity, inflammation, increased mucus production, and intermittent airway obstruction. Respiratory infections, allergens, air pollutants, temperature changes, stress, and exercise can trigger breathing difficulties with asthma, such as coughing, wheezing, and shortness of breath. The mainstay of asthma management is inhaled glucocorticoid (GC) therapy, which directly targets inflammation in relevant airway epithelial cells. Beclomethasone dipropionate, budesonide, flunisolide, fluticasone propionate (FLT), and triamcinolone acetonide are widely used therapeutic agents for asthma in the United States (1). These drugs work via the GC receptor to regulate gene expression leading to decreased inflammation and airway mucus production (2, 3). Although inhaled GC therapy is a vital part of the management of persistent asthma, approximately 30% of all asthmatics have some degree of steroid insensitivity or resistance (3). Insensitivity refers to a poor response to GCs when given in normal, age-appropriate, anti-inflammatory doses, while resistance implies a complete inability to respond to GCs at any dose or at any normal time interval (3). The mechanisms of these responses are not well understood. In the human body, GCs are metabolized by members of the cytochrome P450 3A family in both liver and lung, where they * To whom correspondence should be addressed. Tel: 801-581-7956. Fax: 801-585-3945. E-mail:
[email protected]. † Department of Pharmacology and Toxicology. ‡ Department of Pediatrics.
are known to be differentially expressed (4). Aerosolized drug deposited in the lungs is likely to be metabolized in specific bronchial, bronchiolar, and alveolar epithelial cells, because these cells express significant amounts of P450 3A transcripts and proteins (4, 5). The main pulmonary P450 3A form in human is P450 3A5, whereas P450 3A4 is usually not found in respiratory tissues (6-10). Thus, selective inhibition of one or more P450 3A enzymes could substantially modify airway and systemic concentrations of GCs. CYP3A5 is a polymorphic gene (11, 12), and the CYP3A5*3 allele produces a nonfunctional truncated protein. This genotype is found in about 50% of African Americans and greater than 80% of Caucasians. Thus, less than half of a diverse American population would be expected to have one functional CYP3A5*1 gene and, therefore, exhibit any CYP3A5 enzyme activity in their liver or lung tissues. In general, P450-mediated drug metabolism results in the formation of more polar and pharmacologically inactive metabolites. Metabolism can produce reactive electrophiles that can covalently bind to intracellular macromolecules, potentially causing drug toxicity. Reactive metabolites formed in the active site of P450s may covalently bind to the enzyme itself, causing mechanism-based inactivation (13). This type of inactivation can lead to serious pharmacokinetic variations for drugs and promote potentially dangerous drug-drug interactions (14) because of the irreversibility of the inactivation process and reduced inactivation and clearance of drugs. While higher doses of inhaled GCs usually improve airway responses, they may produce dose-related systemic adverse
10.1021/tx100124k 2010 American Chemical Society Published on Web 07/22/2010
InactiVation of P450 3A5 by Fluticasone Propionate
effects, such as adrenal suppression, decreased bone mineral density, cataracts, and growth suppression (15-17). The safety of high doses, particularly those of FLT, has been questioned by several reports of life threatening acute adrenal crisis in children (16, 18, 19). Systemic bioavailability of inhaled GCs predominantly arises from absorption from the lung. Although the greater part (about 80%) of an inhaled dose will be deposited in the oropharynx, swallowed, and absorbed from the gastrointestinal tract, it is predominantly inactivated via first-pass hepatic metabolism including metabolism by P450 3A4 and 3A5. However, a small portion (∼20%) can be absorbed and/ or metabolized in respiratory tissues with high absorption capacity (20, 21). If metabolism occurs during respiratory absorption, changes in metabolic enzymes could alter local concentrations of active drug or systemic concentrations in some cases. Singh et al. (22) reported that the mean systemic bioavailability of a single 1000 µg of an inhaled dose of FLT was 21.2% (14.3-31.4%) in healthy adult volunteers and 13.3% (8.5-21.9%) in the adult patients with chronic obstructive pulmonary disease. Cmax values in diseased individuals (1961 pg mL-1 h-1) were half of the maximum concentration in healthy patients (2996 pg mL-1 h-1). Bioavailability after administration by the iv route was not altered by the disease. Since high first-pass, hepatic metabolism of FLT by P450 3A4 makes oral absorption of active drug into the systemic circulation negligible (
